Study finds 'unacceptably high percentage' of high schoolers who sustain catastrophic head injury play with residual effects of prior head injury

The incidence of catastrophic head injuries in football is dramatically higher at the high school level than at the college level, according to a study published in the July issue of The American Journal of Sports Medicine.

Catastrophic head injuries, which include brain bleeding and swelling, are rare and can be devastating. Athletes with major brain injuries may be left with permanent brain damage.

"High school football players have more than three times the risk of a catastrophic head injury than their college peers," says lead author, Barry P. Boden, M.D., from the Orthopedic Center in Rockville, Md., and adjunct associate professor at the Uniform Services University of the Health Science in Bethesda, Md.

Boden and coauthors also found a high percentage of high school athletes playing with neurologic symptoms from a previous head injury at the time they sustained a catastrophic injury.

Football has more direct catastrophic injuries than any other sport tracked by the National Center for Catastrophic Sports Injury Research (NCCSIR). More than 1.2 million high school athletes played football during the 2001-2002 academic year.

The researchers reviewed 94 incidents of severe football head injuries reported to the NCCSIR during 13 football seasons (Sept. 1989 through June 2002). Catastrophic injury was defined as either direct (resulting from playing the sport) or indirect (resulting from systemic failure secondary to play), and further subclassified those injuries as fatal, nonfatal (injury causing permanent neurological damage), or serious (while severely injured, the player's injury is immediately relieved, there is no permanent functional disability, and the player recovers completely).

The researchers found that there is approximately one injury per every 150,000 athletes playing, or 7 catastrophic injuries yearly. There were 0.67 injuries per 100,000 players at the high school level and 0.21 injuries per 100,000 for college level football players.

"The incidence of injury is higher at the high school level compared to the college level, which may indicate that the younger brain is more susceptible to a brain injury," explains Dr. Boden. "Many of the players who had a severe head injury were playing with minor neurological symptoms from a previous head injury such as a concussion."

From the 94 cases studied, 59 contacts and/or medical records revealed information on prior head injuries. Fifty-nine percent (35/59) of the injured football players had a history of previous head injury of which 71% (25/35) occurred during the same season as the catastrophic event. Nearly 40% (21/54) of the injured athletes were playing with residual neurologic symptoms from prior head injury. The catastrophic injuries resulted in 8 (9%) deaths, 46 (51%) permanent neurologic injuries, and 36 (40%) serious injuries with full recovery.

Dr. Boden suggests that players should be discouraged from using their heads to tackle, since 81% of the injuries were caused by helmet-to-helmet collisions (16/37) and helmet-to-body collisions (14/37).

One of the study's co-authors, Robert C. Cantu, M.D. of Emerson Hospital, Concord, Mass., has studied catastrophic injuries in many sports. He says that although catastrophic head injuries in football have declined since special regulations went into effect, players are still being returned to the field with symptoms of a prior head injury.

"The single most important piece of advice that I can give is to never let an athlete play football if he has any neurological symptoms whatsoever," says Dr. Boden. "Those symptoms may include amnesia, dizziness, headache, irritability, and personality change."

Of the difference in catastrophic head injuries between high school and college players, Boden theorizes: "High school students might take longer to recover from a concussion than college players. Another possible reason for these reported injuries may be that there aren't as many team physicians covering high school games as college games. Consequently, some high school athletes may not be properly evaluated or receive medical attention."

"Football is a very macho sport. Athletes are taught to play through pain," concludes Dr. Boden. "But concussions need to be taken seriously. Many of them are probably being overlooked at the high school level. These injured athletes are allowed to return to play before full recovery, leaving them susceptible to a more significant injury."

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The American Journal of Sports Medicine is the monthly peer-reviewed scientific journal of the American Orthopaedic Society for Sports Medicine (AOSSM). AOSSM is a world leader in sports medicine education, research, communication, and fellowship. The Society works closely with many sports medicine specialists and clinicians to improve the identification, prevention, treatment, and rehabilitation of sports injuries. Please visit sportsmed/.